The Accreditation/Performance Improvement Consultant (A/PIC) is administratively responsible and accountable to the Chief, Performance Improvement Management Service or designee. The incumbent is assigned to the Performance Improvement Management Service (PIMS) which is aligned under the Director's Office. The Accreditation/Performance Improvement Consultant (A/PIC) demonstrates knowledge of current concepts, principles and tools of performance improvement, internal and external accreditation/regulatory standards, and customer satisfaction. The A/PIC demonstrates advanced leadership skill in developing, implementing, and evaluating programs/processes that facilitate the delivery of safe patient care and facility-wide process improvement, through the utilization of the nursing process, recognized standards of care/ practice, and continuous quality improvement principles. The incumbent serves as an expert consultant/facilitator/trainer/technical advisor to staff at all levels to ensure facility compliance with accreditation/regulatory standards, that include but is not limited to The Joint Commission (TJC), and the Office of the Inspector General (OIG), Commission on the Accreditation of Rehabilitation Facilities (CARF), Long Term Care Institute (LTCI) continuous readiness and supports the organization's Performance Improvement and Patient Safety Programs. The A/PIC ensures compliance with TJC annual review, evaluation, and submission to TJC of the Focused Standards Assessment (FSA), and coordinates facility continuous readiness and compliance efforts relating to TJC assigned program/s (Hospital, Home Care, and Behavioral Health). In addition, the A/PIC demonstrates leadership, experience, and creative approaches to assist members of the healthcare team in the identification and management of quality of care concerns; participates in the identification, analysis, and resolution of healthcare delivery problems; initiates and leads multidisciplinary performance improvement (PI) projects/teams; and participates in planning for improved processes within the VA San Diego Healthcare System (VASDHS). The A/PIC serves as a consultant and technical advisor to members of the interdisciplinary healthcare team, in the development and implementation of tools and processes designed to monitor compliance with regulatory standards, quality and performance metrics, and to improve healthcare processes/systems. The incumbent coordinates Continuous Readiness efforts including assessing, planning, improving and maintaining compliance with external accreditation standards/requirements specific to TJC, CARF and others as appropriate. Serves as liaison for pre-survey (e.g. TJC and CARF applications for survey) and on-site survey activities, as well as facilitates action plans, development of evidence of standards compliance, and related responses to inquiries/reports regarding accreditation findings. Facilitates the review of TJC complaints and coordinates written responses to complaints with involved stakeholders. The A/PIC demonstrates outstanding communication skills, acting as an advocate for improving quality patient care, healthcare outcomes, and healthcare delivery systems in support of Veterans Healthcare Administration (VHA) goals and initiatives at the local, VISN and national levels. The incumbent collaborates with Patient Safety to ensure compliance with TJC National Patient Safety Goals. The incumbent is competent and able to carry out the responsibilities of his/her PI Consultant colleagues. Work Schedule: 0730 - 1600 Financial Disclosure Report: Not required
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.